Burns

Question 1

First degree burn

Answer 1

Superficial partial thickness (sunburns)
Injury to epidermis 
Leaves skin pink or red but no blisters
Dry and painful 
Slight edema

Question 2

Second degree burn

Answer 2

Deep partial thickness destruction of epidermis and upper layers of dermis
Painful and sensitive to touch and cold air
Appears red or white , weeps fluid, blisters are present
Hair follicles in tact
Blanching followed by capillary refill
Usually doesn’t scar

Question 3

Third degree burns

Answer 3

Full thickness and deep full thickness
Involves total destruction of dermis and epidermis
Skin cannot regenerate
Requires skin grafting
Underlying tissue may be involved
Wound appears dry and leathery as eschar develops
Painless

Question 4

Rule of nine with burns

Answer 4

Head and neck= 9%
Upper extremities= 9% each 
Lower extremities= 18% each
Front trunk=18%
Back trunk=18%
Perineal area=1%

Question 5

First stage of burn care

Resuscitative/emergent phase

Answer 5

Begins at time of injury
Concludes with restoration of capillary permeability which typically reverses 48-72 hrs following injury
Characterized by fluid shift from intravascular to interstitial and shock
Focus of care is to preserve vital organ functioning
Expect to administer large volumes of fluid in this phase based on clients weight and extent of injury

Question 6

Second stage of burn care

Acute phase

Answer 6

Occurs from beginning of diuresis(48-72 hrs after injury)
Concludes nearly at the completion of wound closure
Characterized by fluid shift from interstitial to intravascular
Focus is on infection control, wound care, and closure, pain management, nutritional support, and physical therapy

Question 7

Third stage of burn care

Rehabilitation phase

Answer 7

Occurs from major wound closure to return to optimal level of physical and phsychosocial adjustment (5 years apprx)
Characterized by grafting and rehabilitation specific to the clients needs

Question 8

Absence of bowel sounds on burn may indicate

Answer 8

Paralytic ileus

Question 9

Burn patients usually have a decreased urinary output for the first

Answer 9

72 hours after injury with increased specific gravity

Question 10

Burn patients have radically increased urinary output after

Answer 10

72 hours-2 weeks after initial injury

Diuresis

Question 11

Signs of inadequate hydration

Answer 11

Restlessness
Disorientation
Decreased urinary volume and urinary sodium and increased urinary specific gravity

Question 12

Signs of inhalation burn

Answer 12

Red or burned face
Singed facial and nasal hairs
Circumoral burns
Conjunctivitis
Sooty nasal mucous or bloody sputum
Hoarseness
Asymmetry of chest movements with respirations and use of accessory muscles indicative of pneumonia
Rales, wheezing, and ronchi denoting smoke inhalation
Impaired speech and drooling indicating laryngeal edema

Question 13

Nursing interventions for burns

Answer 13

Extinguish source of burn
source
Provide open air way
Administer tetanus toxoid
Initiate fluid and electrolyte therapy (ringers lactate solution with electrolytes and colloids
Insert NG tube
Administer IV pain meds
Monitor hydration status and weigh daily
Prevent infections ( life threatening risk for those with burns)

Question 14

Nursing intervention for chemical burns

Answer 14

Flush with water or normal saline

Question 15

Nursing interventions for electrical burns

Answer 15

Separate client from electrical

Question 16

Burns

Answer 16

Tissue injury or necrosis caused by transfer of energy from heat source to body

Can be thermal, radiation, electrical, or chemical

Body systems affected: resp, integumentary, cardiovascular, renal, GI, neurologic

Severity is determined by burn depth